Reflux Questionnaire

Acid Reflux presents itself with a variety of symptoms. Our goal is to provide you options that improve your quality of life.





Quality of Life Questionnaire

If you have daily heartburn or other acid reflux symptoms, fill out the Quality of Life questionnaire below to assess to what degree it is impacting your life. Print off the calculations and bring it to your next doctor’s appointment for your physician to review.

Directions: Check the box to the right of each question which best describes your experience over the past 2 weeks.



Scale:
0 = No Symtopms
1 = Symptoms noticeable and bothersome
2 = Symptoms noticeable and bothersome,but not every day
3 = Symptoms brothersome every day
4 = Symtoms affect daily activities
5 = Symtoms are incapacitating, unable to do daily activities

Questionnaire Scores

Based upon your Quality of Life Total Score:

  • If your total is between 1-5: your symptoms appear to be mild. Book an appointment to discuss your options to improve your symptoms.
  • If your total is between 5-10: you may have significant reflux symptoms. Book an appointment to discuss your options to improve your symptoms.
  • If your total is greater than 10: you appear to have severe reflux symptoms. You should discuss your results with one of our specialists.

If you’d like to print the results of your questionnaire for you meeting with the surgeon, press print icon.

References

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